Skin Hooks

Skin hooks are small handheld retractors with one or more sharp or blunt hooks at the working end. They provide point traction without opposing forceps jaws, but sharp models puncture tissue and are neither trauma-free nor free of sharps risk. Hook instruments have a long surgical history; current Joseph, Guthrie, Gillies and other patterns vary in prong count, spacing, handle and intended specialty.^[1][8][9]

In reconstructive urology, skin hooks are used for fine wound-edge exposure; a current commercial urethroplasty set includes single- and double-prong Joseph hooks and a Guthrie double hook.^[8] The Clark survey documents dermatologic-surgeon use patterns, not superior genitourinary cosmetic outcomes.^[4]

Design

• Working end: dimensions and bend vary by model; current catalog examples range from single-prong Joseph hooks to double-prong models with 2–12 mm spacing.^[8][9]
• Tip variants:
  • Sharp single-prong. Pointed tip penetrates the dermis for secure grip; the standard.
  • Blunt hook. Rounded working end intended to reduce puncture risk; survey data suggest a possible exposure-safety benefit but cannot establish causality.^[2]
  • Double-prong. Two hooks with model-specific spacing; two contact points do not prove lower tissue injury.
• Handle: form and length vary. Current Sklar Joseph examples are 6.25 inches; the current Teleflex Guthrie example is 5.125 inches.^[9]
• Some handles hexagonal or octagonal in cross-section to prevent rolling off the field.
• Material: surgical-grade stainless steel; disposable variants exist.

Named Variants

Variant	Defining feature	Best fit
Joseph skin hook (Jacques Joseph, 1865–1934)	Fine sharp single-prong; rhinoplasty heritage	Fine facial / glanular / labial work
Guthrie	Single sharp prong, dermatologic handle profile	Dermatologic surgery, fine-skin work
Gillies (Sir Harold Gillies, 1882–1960)	Fine single sharp prong; plastic-surgery heritage	Reconstructive flap surgery
Frazier	Slightly larger hook	Neurosurgical / ENT applications
Double-prong	Two parallel hooks	Wider / fragile wound edges
Walton fish hook	Blunt wire hook + elastic-band traction	Semi-self-retaining retraction, head-and-neck dissection[3]
Retractable / safety hook	Retractable tip or protective sheath	Sharps-injury reduction

Mechanism — Single-Point Traction, No Crush

The skin hook's mechanism differs from opposing-jaw forceps:^[1]

1. Single-point engagement. The sharp tip is inserted into the dermis (not the epidermis alone, which would tear); engages a small volume of dermal collagen at a single point.
2. Point traction rather than opposing-jaw compression. This can avoid a forceps pinch at the grasp site, but the hook creates a puncture or contact point and may tear tissue.
3. Wound-edge eversion. Controlled lateral or upward traction can expose the dermal edge during closure.
4. Retraction. Single-edge retraction laterally, exposing the underlying tissue plane.

No comparative clinical study reviewed here proved preserved dermal microvasculature, reduced necrosis or a superior cosmetic outcome versus appropriately used fine forceps.

Reconstructive-Urology and Urogyn Uses

Skin hooks may be used for fine skin-edge exposure in reconstructive work; the examples below are practical applications, not comparative outcome indications:

Hypospadias and distal-urethral reconstruction

• Glanular and urethral-plate handling during TIP, TIPU, Mathieu and onlay-island-flap repair, with fine traction on glanular wings, the urethral plate and inner-prepuce flaps without crushing fragile glanular tissue.
• Fistula-repair flap-tip manipulation during urethrocutaneous-fistula repair after hypospadias.

Glansplasty and glans reconstruction

• Glans-resurfacing, partial glansectomy, glanuloplasty. Traction on glanular epithelium and sub-glanular flaps where forceps would crush fragile tissue.

Penile-shaft cosmetic and minor reconstructive work

• Inner-prepuce / preputial-skin handling during partial / radical circumcision revision, frenuloplasty, minor penile-skin reconstruction.
• Penile-shaft flap-tip manipulation during penile-disassembly procedures and complex penile reconstruction where flap-tip viability must be preserved.

Vulvar and introital reconstruction

• Labiaplasty edge handling. Fine traction on labial mucosa and skin during dissection and closure.
• Vestibulectomy, posterior-vestibuloplasty mucosal advancement, Foldès clitoral reconstruction, post-defibulation introital closure. Wound-edge eversion for precise mucosal-skin approximation.

Microsurgical and microsurgery-adjacent

• Vasovasostomy and microsurgical varicocelectomy. Scrotal-skin and dartos edges during the surgical approach (used in conjunction with microsurgical Castroviejo or Gerald instruments at the anastomotic line).
• Penile or genital replantation. Recipient-vessel exposure where skin-edge traction matters.

Wound closure across RU/urogyn

• Wound-edge eversion during suturing. A skin hook can provide controlled edge exposure while the needle is placed. The Clark survey does not prove superior cosmetic closure.^[4]

Office and ED genital procedures

• Meatotomy / meatoplasty, foreskin-injury repair, urethral-caruncle excision, condyloma excision, vestibular biopsy, vaginal-cyst marsupialization.

Skin-flap handling

For a delicate flap edge, a hook can avoid opposing-jaw compression, but excessive penetration or traction can tear or devascularize tissue. Instrument choice depends on tissue thickness, vector and surgeon control; no reviewed study supports an “always hook, never forceps” rule across every flap.

Skin Hook vs Tissue Forceps — The Crush Question

Feature	Skin hook	Adson / fine tissue forceps
Mechanism	Single-point traction	Two-jaw compression
Local injury mechanism	Puncture/tear risk; no opposing-jaw pinch	Compression, tooth/puncture or crush risk depending on model/force
Wound-edge viability	Depends on placement and traction	Depends on forceps design and handling
Wound-edge eversion	Excellent	Variable
Grip security	Moderate (can slip on thin dermis)	Excellent (firm two-jaw)
Sharps risk	Yes (sharp tip)	Minimal
Cosmetic outcome	No comparative superiority established	No comparative inferiority established
Best for	Facial / glanular / vulvar fine work, flap tips	General tissue, deep tissue, non-cosmetic edges

The Clark 2019 survey received 571 responses: 85.1% reported using skin hooks, and fellowship training was the only measured factor with a statistically significant use difference. This is a practice-pattern survey, not an outcome comparison.^[4]

Safety — Sharps Injuries

The sharp tip is the major occupational hazard. Survey data:^[5][6][7]

• In a 60-member Mohs-surgeon survey, 56.7% reported at least one sharps injury within the past year; among those reporting an injury, 14.7% reported a bloodborne exposure. Self-inflicted suture needlesticks were the most common injury.^[5]
• In a separate 336-respondent U.S. dermatology survey, 85.1% reported a career sharps injury, 40.6% of those had an injury within the past year, and 64% reported ever leaving an injury unreported.^[7]
• Skin hooks are specifically identified as a cause of percutaneous injury in dermatologic-surgery practice.^[6]

Mitigation

• Blunt skin hooks when sharp penetration is unnecessary. LoPiccolo's survey found no reported exposures among respondents using blunt hooks, but the authors explicitly stated that firm associations could not be made.^[2]
• Neutral-zone (hands-free) passing for instrument exchange.
• Retractable / sheathed skin hooks when available.
• Hook-tip awareness at all times during the procedure.
• Sharps-container disposal after use.

Limitations

• Tears through thin or fragile skin. In atrophic skin (elderly, chronic steroid use, Ehlers-Danlos), the hook can pull through the dermis. Use tissue forceps or suture-based retraction instead.
• Single-point retraction only. Broader retraction requires multiple hooks or a multi-pronged retractor (Senn, Volkmann).
• Handheld. Requires continuous holding; for prolonged retraction switch to a self-retaining system (Lone Star, Walton fish hook elastic bands).^[3]
• Superficial only. Not for deep tissue, muscle or viscera.
• Tissue-tearing risk under excessive force, particularly in thin or sun-damaged skin.

Technique

1. Pencil grip for maximum precision and fine control.
2. Engage the dermis, not the epidermis alone. The epidermis tears; the dermis holds.
3. Gentle steady traction. The goal is to displace the wound edge just enough to expose the underlying tissue or evert the edge for suturing; excessive force tears.
4. Insertion angle and bite depth are tissue- and model-dependent. The former universal 45° and 2–3 mm rule was not supported by a reviewed source.
5. Use during suturing for wound-edge exposure when controlled traction helps; no comparative cosmetic benefit is established.
6. Avoid repeated repositioning. Each insertion creates a dermal puncture; minimize.
7. Pair with forceps. Used complementarily, hooks at the cosmetically sensitive edges (facial, glanular, labial, flap tips) and forceps at other or deeper areas.
8. Two hooks for bilateral retraction. One surgeon, one assistant.
9. Flap-tip handling requires judgment. Use the least traumatic instrument and force for the tissue rather than an absolute hook-versus-forceps rule.

Comparison Within the Skin-Edge-Retraction Family

Instrument	Points of contact	Tissue trauma	Best fit
Single skin hook	1	Point puncture/tear risk	Delicate skin edges when controlled point traction is appropriate
Double skin hook	2	Two puncture/contact points	Wider edges when model spacing fits the tissue
Senn (Senn-Miller) rake	3	Low-moderate	Broader skin and superficial-muscle retraction
Volkmann rake	1–6	Low-moderate	Skin / muscle / periosteum in wider fields
Adson forceps (toothed)	2-jaw	Moderate (crush)	General skin and subcutaneous

Historical Context

The skin hook is among the oldest surgical instruments in continuous use. Ancient surgical texts from Egypt, Greece, and Rome describe bronze and iron hooks for wound retraction; Hippocrates, Celsus, and Galen referenced hooks in their surgical writings.^[1] The design has evolved from crude metalwork into the refined precision stainless-steel instruments of today, but the core concept, a sharp or blunt curved tip used to engage and retract tissue at a single point, has remained essentially unchanged for millennia. The Joseph (rhinoplasty), Guthrie (dermatologic), and Gillies (plastic-reconstructive) named variants reflect later refinements in handle and tip geometry for specific operative niches.

See also: Senn Retractor, Volkmann (Rake), Iris Forceps, Iris Scissors, Tenotomy Scissors, Lone Star Retractor.

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References

1. Kirkup J. "The history and evolution of surgical instruments. VII. Spring forceps (tweezers), hooks and simple retractors." Ann R Coll Surg Engl. 1996;78(6):544–52.

2. LoPiccolo MC, Balle MR, Kouba DJ. "Safety precautions in Mohs micrographic surgery for patients with known blood-borne infections: a survey-based study." Dermatol Surg. 2012;38(7 Pt 1):1059–65. doi:10.1111/j.1524-4725.2012.02395.x

3. Rogers SN, Davies ES. "An alternative method of intraoperative skin retraction: the Walton fish hook." Br J Oral Maxillofac Surg. 1995;33(5):323. doi:10.1016/0266-4356(95)90048-9

4. Clark S, Truong V, Stasko T. "Hooked on hooks? A study in the utilization of skin hooks." Dermatol Surg. 2019;45(1):74–9. doi:10.1097/DSS.0000000000001644

5. Talebi-Liasi F, Lewin JM. "A cross-sectional analysis of sharps injuries among dermatologic surgeons: a survey of American College of Mohs Surgery members." Dermatol Surg. 2023;49(11):985–8. doi:10.1097/DSS.0000000000003907

6. Kaspar TA, Wagner RF. "Percutaneous injury during dermatologic surgery." J Am Acad Dermatol. 1991;24(5 Pt 1):756–9. doi:10.1016/0190-9622(91)70116-j

7. Donnelly AF, Chang YH, Nemeth-Ochoa SA. "Sharps injuries and reporting practices of U.S. dermatologists." Dermatol Surg. 2013;39(12):1813–21. doi:10.1111/dsu.12352

8. Sklar Corporation. Sklar Urethroplasty Set 98-1548, including Joseph and Guthrie hooks. Current set record

9. Sklar Corporation. Joseph skin-hook product family; Teleflex/Pilling. Guthrie Skin Hook 054126. Sklar current product record · Teleflex catalog record